Dizziness is a debilitating symptom that affects 10-30% of middle-aged and older people (Aggarwal et al, 2000; Colledge et al, 1994). People with dizziness often report poor health outcomes including reduced quality of life, depression, fear of falling and falls (Aggarwal et al, 2000; Colledge et al, 1994; Tinetti et al, 2000). With advancing age, dizziness becomes more prevalent (Aggarwal et al, 2000; Colledge et al, 1994) and has more causes (Maarsingh et al, 2010). Hence, it is difficult for clinicians to establish objectively a diagnosis and deliver effective interventions. Although some studies have used multifaceted therapies to improve dizziness, they have been limited by small sample sizes and short follow-up periods (e.g. Johansson et al, 2001; Andersson et al, 2006) or have focused on a select sample of people (e.g. those with vestibular (inner ear) deficits (Geraghty et al, 2017) thus preventing generalisability of the results.
Our study investigated whether dizziness burden, balance and stepping could be improved by offering people with dizziness one or several therapies targeting their individual deficits. First, 305 community-dwelling people aged 50 years and over performed a comprehensive set of tests and questionnaires: vestibular (inner ear) function and balance, leg strength, vision, cardiovascular function, medical and dizziness history, medications, quality of life, anxiety and depression. Then, participants were randomly allocated to a no-intervention control group (n = 151) or a 6-month multifaceted individualised intervention (n=154) comprising one or more of the following: vestibular rehabilitation (35% [n = 54]), cognitive-behavioural therapy for anxiety and depression (19% [n = 29]), a home-based exercise programme to train balance and lower-limb strength (24% [n = 37]), and/or medical management (e.g. medication review, advice on blood pressure management; 40% [n = 62]). Participants were also asked to provide monthly reports on their dizziness episodes during the 6-month follow-up period. Our primary outcomes were: 1) the dizziness handicap inventory which assesses emotional, physical and functional aspects of dizziness (rated between 0-56 with higher scores representing higher burden), 2) frequency of dizziness episodes during the 6-month follow-up, 3) choice-stepping reaction time, and 4) gait variability.
WHAT DID WE FIND?
Compared to the control group, there was a small (4-point) but clinically meaningful greater reduction on the dizziness handicap inventory for participants in the intervention group at 6 months. Thus, the multifaceted tailored intervention was effective in improving dizziness-related quality of life. It did not, however, affect balance, gait or the frequency of dizziness episodes. The individual interventions were effective in managing the specific aspects of dizziness that they targeted: falls risk (composite physiological function) for the home-based exercise programme, anxiety for the cognitive-behavioural therapy, and balance for the vestibular rehabilitation therapy.
SIGNIFICANCE AND IMPLICATIONS
Our findings suggest that prescribing middle-aged and older people a multifaceted tailored intervention of evidence-based therapies targeting vestibular disorders, poor balance, anxiety and/or inappropriate medications significantly reduces dizziness-related disability. It did not, however, improve physical function – though the exercise program did. Our findings provide a health care model whereby community-based dizziness clinics could use existing healthcare services to implement tailored and multifaceted dizziness interventions to reduce dizziness handicap in middle-aged and older people.
Menant JC, Migliaccio AA, Sturnieks DL, Hicks C, Lo J, Ratanapongleka M, Turner J, Delbaere K, Titov N, Meinrath D, McVeigh C, Close JCT, Lord SR. Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial. PLoS Med 15(7):e1002620, 2018.
Aggarwal NT, Bennett DA, Bienias JL, Mendes de Leon CF, Morris MC, Evans DA. The prevalence of dizziness and its association with functional disability in a biracial community population. J Gerontol A Biol Sci Med Sci 55:M288–92, 2000.
Andersson G, Asmundson GJ, Denev J, Nilsson J, Larsen HC. A controlled trial of cognitive-behavior therapy combined with vestibular rehabilitation in the treatment of dizziness. Behav Res Ther 44:1265–73, 2006.
Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age Ageing 23:117–20, 1994.
Geraghty AWA, Essery R, Kirby S, Stuart B, Turner D, Little P, et al. Internet-Based Vestibular Rehabilitation for Older Adults With Chronic Dizziness: A Randomized Controlled Trial in Primary Care. Ann Fam Med 15:209–16, 2017.
Johansson M, Akerlund D, Larsen HC, Andersson G. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg 125:151–6, 2001.
Tinetti ME, Williams CS, Gill TM. Health, functional, and psychological outcomes among older persons with chronic dizziness. J Am Geriatr Soc 48:417–21, 2000.
Maarsingh OR, Dros J, Schellevis FG, van Weert HC, van der Windt DA, ter Riet G, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med 8:196–205, 2010.
Dr Jasmine Menant is a Research Fellow in the Falls, Balance and Injury Research Group at NeuRA and Conjoint Lecturer in the School of Public Health and Community Medicine at UNSW. Her research spans the understanding of cognitive, motor and environmental factors contributing to postural instability and falls, and randomised controlled trials to reduce falls and improve health outcomes, in aging and clinical populations. To read Jasmine’s other blogs, click here.